Deciphering Dysphagia

Posted by Deborah Grauzam on

by Colette Ellis M.Ed., CCC-SLP, BCS-S

Dysphagia, or having difficulty swallowing, can affect upwards of 15 million adults in the United States alone. Research has demonstrated that as many as 1 in 25 individuals will experience some form of dysphagia in their lifetime, including 22% of those 50 years of age and older (ASHA 2018; Bhattacharyya, 2014). In the elderly, these percentage may be as high as 30% receiving inpatient medical treatment (Lane, Losinski, Zenner, & Amet, 1989). 68% of residents in long-term care setting may experience dysphagia according to the National Institute on Deafness and Other Communication Disorders (NIDCD, n.d.; Steele, Greenwood, Ens, Robertson, & Seidman-Carlson, 1997). In the "healthy elderly," dysphagia may occur between 13-38% among those living independently.

Dysphagia does not discriminate, rich or poor, young or old. If a swallowing problem occurs in the teen population, it is typically a continuation of a feeding/swallowing problem which was present as a younger child, such as the growing child with cerebral palsy.  New onset dysphagia in teens or younger children may be related to specific choking episodes or a sudden onset such as a traumatic brain injury (TBI) (Swigert, NFOSD, 2015). Second only to children 0-4 years of age, teenagers and young adults ages 15-24 experience the most TBI injuries, which can also present with dysphagia (http://www.cdc.gov/traumaticbraininjury/data/). Dysphagia has been estimated to occur in 13% of those individuals suffering a TBI, with gunshot wounds that cause TBI, producing dysphagia upwards of 37% of the time.

This medical condition can often be neglected or misdiagnosed, despite the significand prevalence across all ages. Education and timely referrals are potential keys to successful recovery or management of dysphagia. Including the above, dysphagia can be a consequence of stroke, head and neck cancer, neurological disease onset, Alzheimer’s dementia and other dementias, Parkinson’s disease, and congenital onset conditions. Speech-language pathologists are highly trained in head and neck anatomy/physiology, and can, with collaboration with the patient’s physician, evaluate and treat many forms of swallowing disorders or dysphagia.

But what does all this mean? What are the consequences of dysphagia? In children, dysphagia can lead to failure to meet nutritional and hydration needs, including failure to thrive in infants (Vivanti, Cambell, Suiter, Hannen-Jones, Hulcomb, 2009; Hays & Roberts, 2006). Severe consequences of dysphagia can include asphyxiation and death across all ages (Berzlanovich, et al, 2005), depression and isolation with negative impact on social well-being (Ekberg, et. al, 2002), as well as potential delayed or disordered development of oral and communication skills (Barbosa, Vasquez, Parada, Carlos, Gonzalez, Jackson, 2009; Morris & Klein, 2000). Another obvious, or maybe not so obvious consequence of dysphagia is pneumonia.

In order to evaluate and treat dysphagia, the speech-language pathologist must know how, when and why the symptoms are occurring. After a thorough case history is reviewed, a clinical swallow examination would be in order; in other words, watch the infant, child or adult eat and drink, regardless of their physical setting. If choking or coughing symptoms are noted, along with other risk factors such as recent hospitalizations, poor weight gain, change in current function, pneumonia onset, dehydration with urinary tract infection (UTI), a swallow instrumentation study may be necessary. These studies (the modified barium swallow study MBSS or the fiberoptic endoscopic examination of swallowing, FEES) would identify the anatomy and physiology of that individual’s current status and swallow, while enabling the skilled SLP to trial maneuvers, compensation or exercise while the swallow is "in view," and aid in treatment planning.

If you or someone you care about has been experiencing swallowing problems, encourage them to relay this to their physician and seek an evaluation from a speech-language pathologist skilled in evaluating and treating swallowing disorders. Eating and drinking have many social significances and being deprived of this basic pleasure would be detrimental. Think of this the next time you take that big drink of cool, refreshing water.

***

Here are a few resources to get more information:

References

ASHA, (2002). Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders, Position Statement

ASHA, End-of-Life Issues in Speech-Language Pathology, https://www.asha.org/slp/clinical/endoflife/

Barbosa,C., Vasquez, S., Parada, M.A., Carlos, Gonzalez, J.C., Jackson, C., Yanez, N.D., Gelaye, B., Fitzpatrick, A.L.(2009). The relationship of bottle feeding and other sucking behaviors with speech disorder in Patagonian preschoolers. BioMed Central Pediatrics, Oct 21;9:66. doi: 10.1186/1471-2431-9-66.

Berzlanovich, A.M., Fazeny-Dorner, B., Waldhoer, T., Fasching, P., Keil, W. (2005). Foreign body asphyxia: a preventable cause of death in the elderly, American Journal of Preventative Medicine, Jan;28(1):65-9.

Bhattacharyya, N. (2014). The prevalence of dysphagia among adults in the United States. Otolaryngology-Head and Neck Surgery, 151, 765-769.

Vivanti, Cambell, Suiter, Hannen-Jones, Hulcomb. (2009). Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalized patients with dysphagia. Journal of Human Nutritional Diet, Apr 22 (2)148-155.

Layne, K., Losinski, D., Zenner, P., & Ament, J. (1989). Using the Fleming Index of Dysphagia to establish prevalence. Dysphagia, 2, 216-219.

Morrison, et al., (2004). Palliative Care, NEJM, 350:2582-2590

Steele, C., Greenwood, C., Ens, I., Robertson, C., & Seidman-Carlson, R. (1997). Mealtime difficulties in a home for the aged: not just dysphagia. Dysphagia, 12, 43-50.

Swallowing Disorders Foundation: http://swallowingdisorderfoundation.com/dysphagia-in-teens-adults/ published 03-29-2015.

http://www.cdc.gov/traumaticbraininjury/data/

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"Functional Assessment of Feeding Challenges in Children with Ankyloglossia"

Posted by Deborah Grauzam on

This poster was presented at the 2017 annual American Speech-Language & Hearing Association, Saturday, November 11, 11 a.m.-12:30 p.m.

"Functional Assessment of Feeding Challenges in Children with Ankyloglossia"

Authors: Robyn Merkel-Walsh, MA, CCC-SLPLori Overland, MS, CCC-SLP, C/NDT, CLC

TalkTools | TOTs poster

Click here to view the full poster

Introduction:

Presentation explores 1) current classification systems for ankyloglossia; 2) functional assessment of ankyloglossia; 3) oral sensory-motor feeding challenges associated with ankyloglossia and 4) implications for treatment.

Discussion:

Ankyloglossia is not a newly discovered condition, and about 3% of infants are born with a tongue-tie (Amir, James, & Donath, 2006). The International Association of Tongue-Tie Professionals (IATP) adds that tongue-tie is an embryological remnant of tissue in the mid-line between the under-surface of the tongue and the floor of the mouth that restricts normal tongue movement (IATP, 2016). Three terms are being used synonymously to identify this condition: 1) Ankyloglossia 2) Tongue-Tie and 3) Tethering of Oral Tissues (TOTS). Tethering of Oral Tissues (TOTS) is a fairly new term that was coined by Kevin Boyd, DDS at the International Association of Tongue-tie Professionals at their annual conference in Quebec, Montreal Canada in October of 2014. TOTS as a term is more inclusive of tissue restriction of the tongue, lips and buccal frena (Boyd, 2014). The terms do not seem to be committed to one field of specialty, but the ICD10 coding system introduced in October 2015 is still only using one label for this condition, ankyloglossia (ASHA, 2015).

Over the past few years, this topic has been more frequently discussed in the fields of lactation, speech pathology, oral surgery, orofacial myology and otolaryngology. In a clinical study, lactation consultations, otolaryngologists, speech pathologists and pediatricians were surveyed on their beliefs regarding the impact of ankyloglossia on feeding. 69 percent of lactation consultants, but a minority of physician respondents, believe tongue-tie is frequently associated with oral feeding problems (Messner & Lalakea, 2000).

TalkTools | TOTs pictures

There have been several professionals who have published tongue-tie classification tools such as: Alison Hazelbaker, Lawrence Kotlow and Carmen Fernando. The International Affiliation of Tongue-Tie Professionals (IATP) cautions that classification can never substitute for assessment because classification develops categories based on broad, general criteria whereas assessment uses specific, detailed criteria for the purpose of accuracy and thoroughness (IATP, 2016). Researchers are collecting evidence on the histological characteristics of the frenulum (de Castro Martinelli, Marchesan, Gusmao, de Castro Rodrigues & Berretin-Felix, 2014); however, many professionals cannot agree on a classification system or diagnostic protocol to uniformly label the anomaly.

Despite these classifications systems, there does not seem to be a comprehensive assessment protocol to date that specifically task analyzes function for all stages of feeding skills. The Lingual Frenulum Protocol for Infants provides quick functional assessments for infants who breast and/or bottle feed. The Lingual Frenulum Protocol provides a general functional assessment of feeding and speech skills. These tools assist in determining whether or not a frenulum release is warranted, but do give clinical implications for treatment (Martinelli, Marchesan & Berretin-Felix, 2012).

TalkTools | TOTs diagram

Functional assessment of ankyloglossia considers not only the structure, but the impact on lingual range of motion specifically for the pre-feeding skills required for all stages of feeding. Range of motion observations should include: lip closure as it relates to cup drinking and spoon feeding; lip protrusion as it relates to the breast, bottle and spoon; lip rounding as it relates to straw drinking; lingual retraction as it relates to oral transport of a
liquid or bolus; intraoral lateralization as it relates to chewing; and transporting a bolus and tongue tip elevation as it relates to swallowing (Overland & Merkel-Walsh, 2013). Assessment strategies will be dependent on the age of the child, cognitive ability and motor planning ability.

TalkTools | TOTs table

Conclusion:

In summary, the assessment of ankyloglossia should not be limited to appearance alone. Oral motor skills including pre-feeding and feeding should be task analyzed. Since there is conflicting views on whether or not ankyloglossia should be surgically corrected, assessment must clearly consider the functional impact of the tongue-tie on feeding challenges (AABM, 2016; Ferres-Amat, Pastor-Vera, Ferres-Amat, Mareque-Bueno, Prats-Armengol & Ferres-Padro, 2016; Francis, Chinnadurai, Morad, Epstein, Kohanim, Krishnaswami, Sathe & McPheeters, 2015; Kummer, 2016; Merdad & Mascarenhas, 2010;
Sethi, Smith, Kortequee, Ward & Clarke, 2013).

References:

American Academy of Breastfeeding Medicine (AABM). (2016). Protocol # 11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Retrieved from: http://www.bfmed.org/Media/Files/Protocols/ankyloglossia.pdf

Amir, L.H., James, J.P. & Donath, S.M. (2006). Reliability of the Hazelbaker assessment tool for lingual frenulum function. International Breastfeeding Journal, 1(3).

American Speech-Language-Hearing Association (2015). ICD-10-CM Diagnosis Codes for Audiology and Speech-Language Pathology Preparing for Implementation. Retrieved from: http://www.asha.org/Practice/reimbursement/coding/ICD-10/

Boyd, K. (2014). Impact of tongue-tie over a lifetime: an anthropological perspective. Presentation at the IATP 2nd World Summit. Montreal, Quebec.

de Castro Martinelli, R.L., Marchesan, I.Q., Gusmao, R.J., de Castro Rodrigues, A. & Berretin-Felix, G. (2014). Histological characteristics of altered human lingual frenulum. International Journal of Pediatrics and Child Health, 2, 5-9.

Ferres-Amat, E., Pastor-Vera, T., Ferres-Amat, E., Mareque-Bueno, J., Prats-Armengol, J. & Ferres-Padro, E. (2016). Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Journal of Oral Medicine and Pathology, 1:21 (1):39-47

Francis, D.O., Chinnadurai, S., Morad, A., Epstein, R.A., Kohanim, S., Krishnaswami, S., Sathe, N.A. & McPheeters, M.L. (2015). Treatments for ankyloglossia and ankyloglossia with concomitant lip-tie. Comparative Effectiveness Reviews, No. 149. Agency for Healthcare Research and Quality. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK299120/.

International Affiliation of Tongue-Tie Professionals (2016). Classification. Retrieved from: http://tonguetieprofessionals.org/about/assessment/classification/

Kummer, A. (2016). To clip or not to clip? That’s the question. Presented at the annual convention of The American Speech-Language-Hearing Association. Philadelphia, PA.

Martinelli, R.L., Marchesan, I.Q., & Berretin-Felix, G. (2012). Lingual Frenulum Protocol with Scores for Infants. International Journal of Orofacial Myology, 38, 104-113.

Merdad, H. & Mascarenhas, A.K. (2010). Ankyloglossia may cause breastfeeding, tongue mobility, and speech difficulties, with inconclusive results on treatment choices. Journal of Evidence-Based Dental Practice, 10(3):152-3.

Messner, A.H. & Lalakea, M.L. (2000). Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology, 54(2):123-31.

Overland, L. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC: TalkTools.

Sethi N., Smith D., Kortequee S., Ward V.M. & Clarke S. (2013). Benefits of frenulotomy in infants with ankyloglossia. International Journal of Pediatric Otorhinolaryngology, 77(5): 762-5.

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SPD: Know The Signs, Characteristics & How To Get Help

Posted by Deborah Grauzam on

TalkTools instructor Monica Purdy, MA, CCC-SLP & mom of three, nurse and author Michele Gianetti, RN have recently been published in Parenting Special Needs Magazine in the July/August 2017 edition.

"SPD: Know The Signs, Characteristics & How To Get Help" is available for free through the online magazine.

The article is valuable for parents of children with Sensory Processing Disorder, providing them with a downloadable checklist and a sample letter for their child's teacher and school, in addition to three pages of tips, facts and essential information throughout the article. The resources are intended to help special needs children and their families getting back to school smoothly.

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3 Presentations at NDSC 2017!

Posted by Deborah Grauzam on

TalkTools was represented in 3 presentations at this year's National Down Syndrome Congress. Thank you all for attending!

Effective Strategies For Improved Communication and Speech Clarity for Children with the Diagnosis of Down syndrome

Presenter: Jennifer Gray, MS, CCC-SLP

Age range: Birth to 8

Course description:

This presentation will focus on effective communication strategies for children, birth to
school-aged, with the diagnosis of Down syndrome. Factors that impact appropriate
communication will be presented. Strategies will be discussed that foster speech and
language and prevent communication difficulties. Sensory, motor, and oral-placement
skills will be discussed in the framework of a comprehensive language learning system.
Parents and educators will better understand how multiple strategies can be implemented
to address speech clarity and overall communication.

Learning outcomes:

  • Identify the types of communication and which to target based on the child's strengths in daily living.
  • Learn specific activities and strategies to use at home with your child/client/student to encourage speech clarity and expressive language
  • Learn specific activities and strategies to use at home with your child/client/student to encourage speech clarity and expressive language

Airway, Orthodontics, Apnea, and Oral Placement Therapy

Presenters: Brian Hockel, DDS & Heather Vukelich, MS, SLP-CCC

Age range: All ages

Course description:

Posture and function of the jaw and mouth muscles will affect speech, facial and jaw development, and even the airway. As breathing and speaking are vital to health and personal development, you will want to learn in this presentation how to optimize your child's potential through addressing the common root causes of speech, orthodontic, and sleep apnea problems.

Learning outcomes:

  • To understand the etiology of facial and airway growth, and the implications for sleep apnea.
  • To introduce therapies such as Oral Placement Therapy that help speech and facial development.
  • To show orthodontic approaches which affect speech, facial appearance, and airway health.

Understanding Sensory Differences and How It Can improve Your Child's Quality of Life

Presenter: Monica Purdy, MA, CCC-SLP

Age range: Birth to 5

Course description:

The term “Sensory Differences” has been recently added to the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5®). Sensory differences can affect how each of us perform in therapy, school or their home setting. An individual’s sensory system is the foundation of his/her ability to interpret, process and react to the demands of the environment. Sensory differences affect every facet in an individual’s life – from eating, articulation, language, social and academic skills to self-care and play.

This course will allow participants to evaluate sensory differences, and gain new insights and perspectives toward your child, and even yourself. Understanding the importance of modulation, as well as under-responsive or over-responsive actions, will be the basis for guiding you and your child's therapist to have more success in every day interactions, as well as therapy sessions.

The importance of recognizing how your child may be processing information, and understanding which strategies and practices to implement will help your child both in therapy – and in life. The importance of working in conjunction with an occupational therapist will also be addressed.

Learning outcomes:

  • Define the term sensory processing disorder and determine how sensory processing affects your child
  • Identify the 8 senses and distinguish between typical and non-typical reactions to sensory input
  • Apply sensory activities to help the child/client achieve success
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#tbt: My Best Tips For Eliciting The K Sound

Posted by Deborah Grauzam on

This is a repost from Dean Trout’s Little Shop of SLP, with permission from the author.

Upon reaching out to her for permission, here's what Dean wrote: "I found TalkTools to be great for oral awareness and teaching segmentation of articulators!"

TalkTools | Dean TroutDean Trout worked for 31 years as a Speech Therapist in the public school system and for 4 years in her own speech clinic. She started 2 Gals Speech Products, LLC in 2007, spoke at several speech conferences and have been published in the ASHA Leader. Today she creates tangible things that she sells in her Etsy store as well as digital downloads in her TpT store"For you who are new to the field of SLP, I want to give tips and tricks to make your therapy more effective. ... For you more mature SLPs I want you to feel comfortable with technology and social media." 

April 10, 2017

TalkTools | K Sound (Dean Trout)I have often felt baffled as to why kids cannot produce /k/ when developmentally we make posterior sounds before anterior. Think about it, a baby’s first sounds are goo-goo and ga-ga, so isn’t /k/ just a naturally developing response? It makes me go, hmmm. Luckily there are several ways to go about teaching this sound. These tips are not in any particular order, so don’t think Tip #1 is the best. All these tips have been used successfully by several of my colleagues and me.  Please remember what works with one child does not always work with another. We are simply sharing some ideas of things to try.

TIP #1 Cue with “Clear out the Popcorn”

This tip is not EBP and I am not trying to pass it off as such.  I am just sharing an out of the box idea for when all else has failed.  In my many years of practice, I have found that the major reason a child cannot imitate a sound from our model and demonstration is simply that they don’t understand what we are telling them to do. They just don’t “get it.” It also seems that they more often than not just don’t get it when we try to show and explain how to do those sounds that are made in the back of our mouths: /k/, /g/, /r/. So to help them “get it” I try to relate the sound to something to which they are familiar. Most all of us have eaten popcorn and don’t we all, at times, get a husk caught on the back of our tongue and have to clear it out? That is what I use to help them understand what I mean by the back of the mouth or back of the tongue, etc. Every child I have had in therapy can show me with 100% accuracy where the front and back of the mouth is located on a drawing and can point to the front and back of their own mouths, but yet cannot put their own tongues there. To teach them how to find and lift the back of their tongues, we practice that horrible hacky-growly guttural sound we make when clearing out the popcorn. We do this until I feel they fully understand what I mean when I say use the back of your tongue. Once they “get it” you can shape it into a beautiful /k/ in isolation and begin your regular therapy. If they forget to get their tongue up when drilling syllables or words, just cue with “clear out the popcorn.”

If you really want to be the fun “speech teacher” why not bring some popcorn to eat in therapy? Just check for food allergies first ;)

TIP#2 Cereal

You can also get correct tongue positioning for /k/ using cereal-Cheerios or Fruit Loops. This approach is taught by Sara Rosenfeld-Johnson in her Talk Tools program. Basically, what you do is place the cereal behind the bottom front teeth and have the child place the tip of his tongue in the cereal hole and hold it there to keep the tip down while making the /k/ using the back of the tongue. This technique is explained in detail in the Talk Tools program. Here is the link to the website. http://www.talktools.com/ I highly recommend you learn how to implement this technique because it is effective. It is great for kids who front the back sounds and need the tactile cueing.

TIP #3 Tactile Cues—Holding the Tip and Blade

For years I have had kids to use their own finger to hold the tongue tip down to get the correct position for /k/ when they were substituting /t/ for/k/. Many times they will have to not just hold the tip but the tongue blade as well. You can start out with them holding only the tip down while they say /k/, but if they start making the /k/ with the blade of their tongue mid palate you will have to have them hold more of the tongue down and push the tongue further back in their mouths. This has been exceptionally effective at achieving a good /k/ sound. Many people do not like this approach, but if it works then I say use it. I have had some kids who have had to use their finger to hold their tongue down not only in isolation but through syllable and even a few into words (gasp)! However, never fear, I have never had a kid graduate from speech therapy and still have their finger in their mouth!! I never ask them to quit using their finger. They eventually get tired of using it and stop on their own. Don’t you think we sometimes worry too much about the little things?

When implementing this strategy if you are the one holding the child’s tongue via your own gloved hand, finger cot, or tongue depressor be careful of a hyper gag reflex. If you find a child with a hyper gag, you have two choices: 1) desensitize the gag reflex or 2) don’t use this approach. If the child can tolerate you inside his mouth a nice little tip is to use flavored toothpaste on a dental swab. It is just less invasive tasting.

TIP# 4 Use Gravity

Some children need a little more help learning to elevate the back of their tongue, and gravity helps! There are suggestions to have the children let their head lean over the back of their chair or have them lie on the floor. Personally, I have had no success with using the chair technique. I have had success doing therapy while the child is lying on his/her back on the floor. Initially, I just have the child lie on his back on the floor and do some deep breathing exercises to help him relax. I will sometimes lay a book on his stomach for this. They can see the book rise and fall as they breathe. After the child looks relaxed and at ease with lying on the floor, I begin therapy using the other techniques explained in this article. The one that seems to work the best is using tactile cues. I will start with a tongue blade and gently “push” the tongue tip down toward the back of the mouth. If this doesn’t work, I try having the child “cough” really hard, (similar to the clearing of the throat.) Usually, this combination of techniques works within one to two sessions, and we can go back to sitting in our chairs for therapy.

TIP#5 Getting Tongue Retraction

You cannot produce a /k/ without your tongue retracting back into the mouth. To achieve a tongue retraction response, stimulate midline of the tongue from anterior to posterior with a tongue depressor or your gloved finger. Pam Marshalla explains this very well on the websitehttps://pammarshalla.com/stimulating-tongue-back-elevation-for-k-and-g/

I suppose this sums up every tip and trick we have up our sleeves. Hopefully, this has affirmed that what you’re doing is right or maybe even got you to thinking it is ok to try something off the wall in therapy.  I am all for Evidence-Based Practice but sometimes when all else has failed you must try something unique.  It just might work for this particular student.  

I will not discuss or debate EPB, so no need to leave heated comments. 

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